“No man ever does a duty for duty’s sake but only for the sake of the satisfaction he personally gets out of doing the duty…” Mark Twain
Once patients make a health care decision, is the die really cast? Tens of thousands of articles and research papers, written over a millennia or two, describe the paradox created by people seeking the advice of healers. Half choose to ignore their plan of care. It is choice, that ultimate decision by the patient, that determines whether or not he or she will follow your carefully crafted plan of care. The numbers tell us that, if you see 32 patients today, 16 will make the decision to do their own thing.
We label patient behavior with dozens of adjectives to help us understand why anyone with half a brain would not do as we direct. It is, after all, their health, their body and their medical condition. To make matters worse, the primary third party payer is now “incentivizing” providers to give better quality care by withholding earned revenue for unplanned readmissions within 30 days of discharge. What if the patient chooses to not follow their plan of care? The question today is, what is the responsibility of providers to influence patient choice regarding their plan of care? In 2015 the Centers for Medicare and Medicaid clearly stated that care beyond the walls of clinics and hospitals is a “joint” responsibility. How is that to be divided? In a patient centered world, the patient holds the majority. When he or she votes no, is it fair to hold the provider responsible?
Physicians and non-physician providers have a moral and legal responsibility to offer the highest quality service they are capable of. It is their duty to do so. On the other hand, patients are under no such obligation. Following their care plan is most often subjective and based on “… the satisfaction he [the patient] personally gets out of doing…” what is necessary to achieve better health. What if the patient gets no perceived benefit out of doing? Choice is based on what patients believe will happen when the care plan is followed. In acute care, patients often do experience a rapid improvement in their health and have some level of personal satisfaction. The consequences of their behavior are positive, immediate, certain and they are aware of what the treatment did for them. Chronic illnesses offer a completely different scenario. The consequences are typically positive but the benefits, although certain, are in the future and the patient is unaware of anything happening. There is little, if any, “satisfaction he personally gets out of doing the duty.”
Most writers on the subject describe “behavior” as the major cause of non-adherence. Then they list any number of adjectives to support that notion. Lazy, forgetful, cost, side effects, and so forth tell us why people don’t do as they should. To aid my memory, I use the mnemonic “ICE-IF-SAD” to ensure I don’t leave off any “behaviors”. Inconvenience – Choice – Expense – Illness – Forgetful – Side effects – Accepting – Distrust.
If “behavior is what a person does, not what he thinks, feels or believes,” choice is the only behavior on this list. The rest of the words represent why patients don’t follow their plan of care. Inconvenience, expense, and side effects are consequences that “punish” the patient for following their care plan. Paraphrasing Twain, “No patient ever takes a pill or diets or exercises for the doctor’s sake, but only for the satisfaction (reinforcement) he personally gets out of following the plan.” Paraphrasing Jerry Maguire (1996), “Show me the [reinforcers]!”
Where reinforcement flows, behavior goes. When new habits are not reinforced, old reinforcing habits fill the gap. When new habits are “punished” with costs, inconvenient schedules, and side effects, they have no chance to become the new normal. The patient who is “forgetful”, in the absence of organic brain disease, has made a choice. Telling you “I forgot” or “I keep leaving my medication at home” is saying that he or she is getting no satisfaction personally out of doing their duty to themselves.
Behaviors are always surrounded by antecedents or things that get the behavior started (prescriptions, diagnoses) and consequences. Consequences are what happens following a behavior that either increases or decreases the likelihood that it will continue in the future. Illness, Acceptance, and Distrust are not behaviors but rather antecedents. Without the illness there is no need for treatment. If, because of one’s deeply held beliefs, the course of the disease is the will of God, there may be no “call to action” or a resignation to let nature take its course. Acceptance is an antecedent. Distrust of the provider or health services system may have developed based on previous misadventures, real or perceived. Distrust is then a consequence of previous experiences that becomes the antecedent for non-adherence with future illnesses. Ambivalence is a consequence and the mixed feelings are a result of previous direct or indirect experiences. Ambivalence will always find its roots in inconvenience, expenses, side effects, acceptance and/or distrust.
For the 50% choosing to ignore or loosely follow your plan of care, adherence is never a roll of the dice. It is most likely a set of consequences that either punished or failed to reinforce previous episodes of care. Patient choices are more powerfully reinforced by the 8,759 hours they spend with family and friends than the 15 minutes they spend with you once every three months. Be thankful they sleep for 2,920 of those hours or non-adherence might be higher. A provider’s understanding the science of behavior may not influence all of the non-adherent patients in your practice, but it will give you a better understanding to the question, “Why would anyone in their right mind not follow my plan of care?” If you know that, you can begin to design and implement an Adherence Improvement Plan. Click to find out how!